Pen-i-ten-shurry.

"You," she said grimly, through clenched teeth, "are gonna end up in the pen-i-ten-shurry for this. They're gonna come let me out tomorrow and you're gonna go to the pen and I'm gonna laugh when the cops come to get you."

It was three-and-a-half hours into a four-hour drama, and I was getting rather tired of the situation. I replied, as calmly as I could, that I was not going to the penitentiary or to jail or to hell, no matter how often she repeated those suggestions, and that she was not getting out of this place tomorrow.

Subarachnoid hemorrhages are weird things. They happen most often when an aneurysm, a weak area in an artery, cuts loose and bleeds. What happens next is confusing and fascinating; the patient ends up with what's essentially a sterile meningitis (inflammation of the coverings of the brain and spinal cord). The ability to speak clearly sometimes disappears temporarily, and the person tends to take long vacations from reality.

Combine a subarachnoid hemorrhage with a couple of other organic problems that have already caused substantial damage, then add on a subdural hematoma. That's bleeding under the toughest layer of meninges that cover the brain, and is most often caused by a blow or counter-blow injury to the head. Subdural hematomas fall under the category "walk, talk, and die", because they tend to expand rapidly, compressing the brain tissue under them and on the opposite side of the brain. We keep SDH patients under close observation for several days for that reason.

Even if those patients aren't wandering off the floor, attacking ICU nurses when said nurses don't come up with discharge paperwork, and begging to be left alone long enough to have a quiet cigarette outside.

Had I been able to, I would've ordered a toxicity screen, both blood and urine. Unfortunately, after she came back upstairs from the lobby of the ICU, I had been busy holding her down. For three and a half hours. That kind of energy--the sort of energy and strength that allows an 80-pound patient to break through soft restraints and a restraint vest and requires 160-pound me to kneel atop her--doesn't come only from a subarachnoid hemorrhage or subdural hematoma.

It started innocently enough, with a long-distance phone call to her elderly mother, asking Mom to come pick her up. When Mom arrived, having not checked with the nurses to determine whether she could take her daughter home, things went straight to hell. The patient, amazed and angry that she wasn't going home, became increasingly violent. We got Mom out of there pretty sharpish when it was obvious that we would have some serious work to do.

The end toll on the patient goes like this: ten milligrams of Haldol IM, three of Versed IV, eight of Ativan IV, and four-point soft restraints, Posey vest, and bruises on wrists and ankles where people had to hold her down. (Note for nonmedical types: that's enough sedative and antipsychotic medication to take down a 200-pound man and make it necessary to bag him. She just got calm.)

Oh, and I ran a fourteen-gauge (note for nonmedical types: a fucking huge) IV into her left ankle with one stick. She didn't like it, but I felt better.

The end toll on the staff is as follows: One black eye, one certainly sprained and possibly broken finger, one sore back (that's the only one that's mine, thank God), several puncture wounds from filthy fingernails, and one inch-wide bite wound on a forearm.

The bite wound happened to a very sweet, slightly slow nurses' aide who happened to look away at a critical moment. I feel terrible for her, not least because she had to get vaccinated for tetanus and all the various other things one can get from a human bite, and she hates needles. I will say this, though: she held on like a bulldog even with blood from the bite running down her wrist and hand.

I bought her a pair of heavy black rubber elbow-length gauntlets today at the hardware store. I'll wrap them in pretty pink paper with a girlish bow and give them to her the next time I work.